Couple's name and family name*

Couple's age *

Couple's weight and height? *

Couple's blood group *

Is the menstrual cycle regular? How many days is it bleeding?*

Does she have pain during intercourse?*

How many years did you get married?*

How long have you been trying to get pregnant?*

Have you ever done an in vitro fertilization? several times? When? Please write the exact date.*

How many times did the woman have cesarean section? *

Have you ever done hysterosalpingography (HSG)? Please send report.*

Have you ever done Pap smear? Please send report *

How many times did you get pregnant? *

Have you ever had an abortion? In which week of pregnancy was abortion? why? Please write the exact date*

Are there any genetic diseases in the couple's family? *

Have you ever had surgery? what was that? How many times? *

Do you have one of the common diseases (couples)? Diabetes - Blood pressure - Thyroid *

Are you currently taking a particular drug?*

Can you send the pictures and analysis that you have?*

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